Delirium and coma

1. Delirium and coma
• Presenters
– MANJU BHUDIA(MBChBV)
– OMAIDO BLAIR ANDREW(MBChBV)
• TUTOR
– Dr. LEVI KWARISIIMA

2. OUTLINE
• Defns of delirium and coma
• Common causes of delirium and coma
• Investigations(approach to coma)
• Treatment of delirium and coma

3. Delirium
• Defn
• Also known as acute confusional state
• Has an acute onset and fluctuating
course and inattention accompanied by
either disorganized thinking or an altered
level of consciousness.
• Hyperactive vs hypoactive delirium

4. Causes
Type Common Unusual
Infective Chest infection Cerebral abscess
Urinary infection Subdural empyema
Septicaemia AIDS
Viral illness
Meningitis
Encephalitis
Metabolic/endocrine Hypoxia (respiratory failure) Hypo-/hyperthyroidism
Cardiac failure Adrenal disease
Acute (internal) haemorrhage Porphyria
Hyper-/hypoglycaemia
Hyper-/hypocalcaemia
Hyponatraemia
Liver failure, renal failure
Vascular Acute cerebral haemorrhage/infarction Vasculitis (e.g. SLE)
Subarachnoid haemorrhage Cerebral venous thrombosis
Hyperviscosity

5. Causes contd
Type Common Unusual
Toxic Alcohol intoxication/withdrawal Carbon monoxide poisoning
Drugs (therapeutic/illicit) e.g
anticholinergic properties,
narcotics, and benzodiazepines
Industrial exposure (e.g. heavy
metals)
Neoplastic Secondary deposits Primary cerebral tumour
Paraneoplastic syndrome
Trauma Head injury (cerebral contusions)
Subdural haematoma
Other Post-ictal state Acute hydrocephalus
Perioperative Complex partial status
epilepticus
Acute decompensation of
dementia
Hashimoto's encephalopathy
Altitude sickness
Migraine

6. Diagnosis
• Diagnosis involves careful history-taking.
• Patients are usually disorientated, often in both
time and place, and therefore their account may
not be helpful.
• Take a history from a witness (either a relative or
a carer).
• Examination may yield other clues to the cause
(e.g. pyrexia, or focal chest or neurological signs).
• Often, however, the cause is not immediately
obvious, and a wide screen of tests must be
performed

7. Investigations
First-line Other useful tests
Blood tests Full blood count, ESR Cardiac enzymes
Urea and electrolytes Protein electrophoresis
Glucose Vitamin B12
Calcium, magnesium Copper studies
Liver function tests Syphilis serology
Thyroid function tests Antinuclear antibody (ANA), anti-
double-stranded DNA (anti-
dsDNA), antithyroid antibodies
Tumour markers, prostate-specific
antigen
CNS investigations Head imaging (CT and/or MRI) Lumbar puncture
EEG
Other Arterial blood gases, ECG
Infection screen (blood cultures,
chest X-ray, urine culture)
Viral screen, as appropriate (e.g.
consider HIV) Urinary porphyrins

8. Treatment
• Involves identifying the cause and correcting it if
possible.
• Confused patients should be nursed in a well-lit room.
• During the period of confusion,
• sedative drugs are best avoided, as they may
exacerbate, although occasionally drugs such as
haloperidol (1-10 mg 8-hourly) may be required.
• In delirium tremens (alcohol withdrawal), the
treatment is a tapered course of diazepam(10mg PO 3-
4hrly during first 24 hrs then reduce to 5mg PO 6-8hrly
PRN) with high-dose intravenous thiamin(400mg)